Coastal Prestige Medical Services and Clinic 575 Price Street, Suite 313, Pismo Beach, CA 93449
Your Age: _____ First Name: _______________Last Name: Date:_______
Phone: ____________________Cell Phone: ____________________ Date of Birth: _______
When did your physician or nurse practitioner last examine your breasts?
_____________________________ Do you give yourself regular breast checks?_________
Date of prior Mammograms: ________________ Results: ______________________
Date of prior breast MRI: ___________________Results: ______________________
Date of prior Ultrasound: ___________________Results: ______________________
Date of prior Thermogram: _________________ Results: ______________________
Your age when you had your first period: ___________ Age of menopause: ____________
Are you currently pregnant? Y/N Are you currently nursing? Y/N Are you currently taking
hormones? Y/N
Have you ever taken hormones? Y / N
Premarin/Prempro/Estrace/Evista/Tamoxifen/Estradiol/Testosterone/Birth Control
What type and for how long?
Are you having regular periods? Y / N Date of last period: _____________________
Have you noticed any change/s in your breast/s?
Right/Left For how long?
Lump/s ___ / ___ ____________ Thickening ___ / ___ ____________
Pain ___ / ___ ____________ Appearance ___ / ___ ____________
Nipple fluid ___ / ___ ____________ Other ___ / ___ ____________
Has any blood relative had breast cancer?
Yes / No Her age when diagnosed:
Mother ___ / ___ ___________________ Sister ___ / ___ ____________________
Daughter ___ / ___ _________________ Other ___ / ___ ____________________
Please complete the dates for any of the following procedures or problems you have had:
Right/Left Date: Right/Left Date:
Breast Reduction ____/____ ________ Surgical Breast Biopsy ____/____ _________
Breast Reconstruction ____/____ ________ Needle Biopsy ____/____ _________
Silicone Injections ____/____ ________ Lumpectomy for Cancer ____/____ _________
Breast Implants ____/____ ________ Radiation Therapy _____/____ ___________
Implants Replaced ____/____ ________ Mastectomy ____/____ _________
Mastitis/Abscess ____/____ ________ Cyst Aspiration ____/____ _________
Radiation Treatment ____/____ ________ Injury to Breast ____/____ _________ (Chest/Neck

Coastal Prestige Medical Services and Clinic
I understand that I will be responsible for payment at the time of services rendered.
Patient Signature: ___________________________________ Date: _____________
Name ________________________________________________________ Age: _____
Today’s Date: ________________________ Birth Date: ___________________________
City: _______________________________________ State: _______ Zip: ____________
Phone Numbers: HOME: ______________________________
CELL: ______________________________
Who Referred You to our Practice? _____________________________________

E-mail Address: ____________________________________________________________
I understand that the risk assessment evaluation report generated from my images are intended
for use by trained health care providers to assist in evaluation, diagnosis and treatment. I further
understand that the report does not provide diagnosis of disease, eliminate the possibly that
disease is present and that the report is not intended for self diagnosis or self evaluation.
Payment is due at time of services rendered.
Patient Signature: ________________________________________ Date: _______________
Optional: I give consent to the anonymous use of my Thermal Images and data for
continued research and development of Thermal Breast Health imaging technology.
Patient Signature: ________________________________________ Date: ________________
Coastal Prestige Medical Services and Clinic Thermal Imaging Protocols and Consent
Please check any related items for the evaluating doctor’s consideration.
You cannot be sunburned or have a fever at the time of your examination.
If you are wearing deodorant, please wipe it off before acclimating.
o Did you have chiropractic care, physical therapy or massage therapy today?
o Have you used analgesic creams, balms, magnets or poultice in the last 24 hours?
o Did you consume caffeine or nicotine within 4 hours of your examination?
o Did you shave under your arms in the last 24 hours?
o Did you apply creams, lotions, talcum powder or skin products on your upper torso today?
o Have you exercised within the last 4 hours?
o Please inform us if you have had radiation treatment within the last 6 months.
Thermography of the breasts is a procedure utilizing computerized thermal imaging cameras to
visualize and obtain an image of the heat coming from the surface of the skin. The
thermographic procedure is performed as an aid to the evaluation of abnormal temperature
patterns of the breast which may or may not indicate the presence of a disease process.
Thermography is NOT a standalone diagnostic tool. It is an adjunctive tool, which while reliable,
should be used by the primary care physician along with other diagnostic tests and analysis so
as to arrive at a provisional or more complete diagnosis. No surgical procedure should be based
on breast thermal imaging alone. Physical examination, mammography, ultrasound, palpation,
MRI, biopsy, blood test, etc. are needed to arrive at a final diagnosis.
I understand that I will be disrobed from the waist up to allow the surface of my body to cool to
an ambient room temperature. This procedure does not use radiation, compression, and it has
no known risks or side effects.
The information provided will be made available to my personal physician or others as I so
designate for further diagnosis and analysis in the overall evaluation of my breast health. I have
been given preparation protocols to insure the most accurate thermographic evaluation of my
breasts possible and I agree that I have completed the requirements.
I certify that I have complied with the above protocols and preparation instructions and/or that I
have noted any protocol(s) I was unable to comply with so that a decision can be made as to
whether or not I can have thermographic imaging on the day scheduled.
I understand that Thermography is not a standalone screening.
Having received satisfactory answers to all questions, I consent to the thermographic
Patient’s Signature__________________________________________ Date: _________
Print Patient’s Name
Coastal Prestige Medical Services and Clinic


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